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TRANSFER DOCUMENT CHECK LIST

HOSPITAL HANDOVER TO ANOTHER FACILITY
Resident/Patient Name: Date:

COPIES SENT WITH RESIDENT/PATIENT (CHECK ALL THAT APPLY):

These documents should ALWAYS accompany the patient:

Transfer Summary

Face Sheet

Current medication list or current MAR

Advanced directives Not applicable

POLST (original) or care limiting orders Not applicable

Social service notes

Belongings check list (what is accompanying the patient)

Physician Orders

These documents should be sent IF INDICATED/AVAILABLE:

SBAR(Situation‐Background‐Assessment‐Recommendations) /Nurses progress notes

Most recent H&P

Last 3 days:

Physician progress notes Physician orders Psychiatrist notes

Social services Relevant lab results Relevant radiology reports

Recent discharge summary

Most recent wound photos

Signature of ambulance staff accepting envelope:

(sending facility to retain a copy for the medical record)

This message, together with any attachments is intended only for the use of the individual or entity to which it is addressed and may contain information that is
confidential and prohibited from disclosure. If you are not the intended recipient, you are hereby notified that any dissemination, or copying of this message, or any
attachment, is strictly prohibited. If you have received this message in error, please notify the original sender immediately by telephone or by return fax and shred this
document along with any documents. Thank you.

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 Facility Logo Patient Label

Transfer Summary Form – From Hospital

Name (first, middle initial, last)

Sent to (name):

Date of birth: / / From:

Language spoken: English Spanish Armenian ED Rehab Unit Med/Surg Telemetry
Korean Other: ICU/CCU Geropsych
Written language: English Spanish Armenian Other:
Korean Other:

Contact Person: Is there a proxy for health care decisions: YES NO

Patient has no known representative Name:
Patient has public guardian Name : Telephone:
Responsible party: (Attach copy)
Telephone : Current code status/instructions:
Relationship: SpouseChild Other: Full Code POLST DNR/AND (Allow Natural Death)
Notified of Transfer: YES NO Name: (Attach copy of advanced directive or Original POLST)
Nearest friend or relative:
Telephone:
Relationship : Spouse Child Other:
Treating physician in current setting: Treating physician in new setting (if known):
Name: Name:
Telephone: Telephone:
If additional information needed contact:
Name: Telephone:
Clinical Information
Reason for Transfer:
Acute level of care Rehabilitation Psychiatric Long Term Acute Care Hospice
Other :
Known Diagnoses/Co‐morbidities: Known allergies:

Recent Clinical Information

BP T P R pOx Most recent weight: Scale used: Bed Standing Chair
Date of Last BM: / / Character of last BM: Constipated Normal Soft Loose Diarrhea
Pain Management History
Last pain assessment score (0‐10): Date: / / Time: Pain medication used:
Current Mental Status (at time of discharge) At Risk Alerts
Alert, oriented, follows instructions
Restraint used : Specify:
Alert, disoriented, but can follow simple instructions
Wanders Moderate fall risk High fall risk
Alert, disoriented, but cannot follow simple instructions
Aspiration risk: Specify:
Not alert
Elopement risk Seizure precautions
Physically aggressive
Disruptive behavior:

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 Immunizations/Testing:
Tetanus (date): / / Influenza (date): / / Pneumococcal (date) : / /
TB (date): / / Positive Negative Skin test Chest Xray Comment:

Current Functional Status

ADL Independent Assistance Unable ADL Independent Assistance Unable

Required Required
Bathe Transfer
Dress Ambulate
Eating Cane Crutches Wheelchair
Other:
Personal Hygiene Weight bearing status:
Non‐weight bearing Partial weight bearing Full weight

Motivation to self care

Skin/Wound Care
High risk for pressure ulcer: YES NO Current pressure ulcer/s: YES NO
(Include most recent photos of wound(s). Date of photos: / / )
Stage: I II III IV Stage: I II III IV Stage: I II III IV Stage: I II III IV
Unstageable Unstageable Unstageable Unstageable
Elbow Elbow Elbow Elbow
Upper back Upper back Upper back Upper back
Lower back Lower back Lower back Lower back
Hip Hip Hip Hip
Buttock Buttock Buttock Buttock
Ankle Ankle Ankle Ankle
Heel Heel Heel Heel
Other site: Other site: Other site: Other site:

Current Diet
Regular No added salt Diabetic Cardiac Renal Restricted NA to Gm Other
Swallowing difficulties: Thickener used Special consistency: Soft Mechanically Altered Pureed
Tube feedings Specify: Restricted fluid intake: cc’s
Date of last meal: / / Time of last meal:
Lines/Devices
Peripheral IV Central Line Type: # Ports: Last dressing change: Date: / / Time:
Pacemaker AICD Foley Catheter Dialysis Catheter Feeding tube Specify: PEG G tube J tube
BPAP CPAP NG Tube Other specify:
Isolation Precautions
MRSA VRE C‐Diff Other: Site/s:
Colonized Active infection with current treatment Specify:
Productive Cough Diarrhea with uncontrolled/uncontained incontinence Draining wound (not contained within dressing)
Additional information:
Anticipated Appointments (if known):
Dialysis‐Center: Date: / / Time: Labs needed: Specify:
Physician‐Name: Date: / / Time: Other:

Form Completed By (print) Date Time Contact #

Physician Signature Date Time Contact #

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